Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 150
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
3030 WABASH AVE, SPRINGFIELD, IL 62704-6413
(217) 698-9721
Mailing address
3030 WABASH AVE, SPRINGFIELD, IL 62704-6413
(217) 698-9721
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014150
VIP
—
01
—
17688
MEDICARE
—
01
—
42563
DAVIS
—
01
—
CP2521-6
EYEMED
—
Enumeration date
05/18/2006
Last updated
01/30/2008
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